Provider Demographics
NPI:1306906086
Name:FENNELL, PAYTON GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:PAYTON
Middle Name:GREGORY
Last Name:FENNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:52 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2798
Mailing Address - Country:US
Mailing Address - Phone:828-485-3004
Mailing Address - Fax:828-328-4049
Practice Address - Street 1:4741 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2919
Practice Address - Country:US
Practice Address - Phone:704-365-6730
Practice Address - Fax:704-365-6731
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200601317207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306906086Medicaid
NCNCO734CMedicare PIN
NC1306906086Medicaid